Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | LP4666 | MN |
NPI | 1053464859 |
---|---|
Provider Name | Dr. Robert Gordon Neal |
First Address | White Bear Lake, MN 55110-6207 |
Second Address | White Bear Lake, MN 55110-6207 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/01/2007 |
Last Update Date | 08/07/2007 |